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Blue Cross Blue Shield of Rhode IslandTraditional Medicare · Prior Auth · Physician / Facility · RI · Oncology, Hematology, Neurology +1 moreHigh impact

Codes added to Medicare MDR 10/1/20

Act
by Oct 1, 2020
Effective date
Oct 1, 2020
Identified
Jun 19, 2026

Summary

Effective October 1, 2020, Medicare will require prior authorization through Prime for 10 new drug codes including specialty medications like gene therapy (Zolgensma), cancer treatments (Padcev, Enhertu), and other high-cost biologics. Any claims for these codes submitted without prior authorization will be subject to denial.

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What to do

by Oct 1, 2020 · 3 steps
01Billing team must update system to require prior authorization through Prime for codes C9061, C9063, J0223, J0791, J0896, J1429, J1558, J3399, J9177, J9358, and Q5121.
02Update encounter forms and EMR alerts to remind providers that prior auth is mandatory for these specialty medications.
03Claims submitted without prior authorization will be denied.

Codes mentioned

C9061C9063J0223J0791J0896J1429J1558J3399J9177J9358Q5121

Original notice

Codes added to Medicare MDR 10/1/20
bcbsri.com · Always check the source before changing claims.
View original ↗

Related changes

See all Blue Cross Blue Shield of Rhode Island changes →
CPT code changesHighEffective Jul 1, 2020 · Physician / FacilityBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list

Related policy hubs

Blue Cross Blue Shield of Rhode Island policiesRI policy changesOncologyHematologyNeurologyAllergy & ImmunologyCode C9061Code C9063Code J0223Code J0791Code J0896Code J1429Code J1558Code J3399Code J9177Code J9358Code Q5121

Summaries are AI-assisted. Always confirm against the original payer notice.

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